Shock and sepsis

Recognize shock

• Restlessness or anxiety, confusion; pale, cool, clammy skin.
• A rapid, weak pulse, shallow breathing, sweating, bluish lips, and little or no urine.
• Call for help right away; don't wait for milder signs to get worse.

First steps

• Check airway, breathing and circulation; start CPR if needed.
• Lay the client flat with the legs raised about 12 inches, unless there's trauma, trouble breathing, or cardiogenic pulmonary edema. If raising the legs causes pain or harm, leave the client flat.
• Keep them warm, and give nothing by mouth. Recheck breathing at least every 5 minutes until the team takes over.

Shock by cause

Sepsis

• Life-threatening organ dysfunction from a dysregulated response to infection: an emergency. Untreated, it can quickly lead to organ failure and death.
• It often starts in the lungs, urinary tract, skin or gut. Septic shock is most common in the very old, the very young, and people with weak immune systems.
• Lines and urinary catheters, recent surgery, chemotherapy, steroids and diabetes add risk.
• Signs: fever or shivering, confusion, extreme pain, clammy skin, a fast heart rate or weak pulse, breathlessness.

The first hour

• Suspect sepsis: alert the provider at once and follow the facility protocol.
• Blood cultures first, as soon as possible, ideally before the antibiotic, but don't let them delay it. Results take several days: don't wait for them.
• Antibiotics immediately, ideally within 1 hour, for septic shock or likely sepsis.
• Lactate: normal about 0.5 to 2.2 mmol/L; high means tissues lack oxygen. Repeat lactates help guide treatment.
• A tourniquet left on too long, or a clenched fist, can falsely raise the lactate.

Fluids and vasopressors

• Adults with sepsis-induced hypoperfusion or septic shock: the guideline suggests 30 mL/kg of IV crystalloid within 3 hours. It's not a must for every sepsis client: balanced crystalloids are preferred; reassess the response and watch for overload.
• Isotonic fluids, like normal saline and lactated Ringer's, expand blood volume without shifting water into the cells, which is why they're used for shock.
• The first target is a mean arterial pressure of 65 mmHg. Capillary refill helps judge whether perfusion is improving.
• If the pressure stays low, norepinephrine is the first-line vasopressor; it can start in a peripheral line. The label says to correct low volume first, dilute it, and run it into a large vein; avoid leg veins in older adults or with leg artery disease.
• Check the pressure every 2 minutes until it reaches the target, then every 5 minutes. Taper it slowly: stopping it suddenly can drop the pressure.
• A leak can cause necrosis: stop the infusion, aspirate from the line, and follow local protocol before the antidote, phentolamine.

Arterial lines and hemodynamic monitoring

• An arterial line, usually radial or femoral, gives a continuous pressure reading and easy blood gas samples. In adults, the CDC prefers the radial, brachial or top-of-foot site over the femoral, to cut infection.
• Insertion needs at least a cap, a mask, sterile gloves and a small sterile drape.
• Keep every part of the pressure system sterile, including the flush solution; enter it as little as possible. Use a closed, continuous flush system, and scrub an access port with antiseptic before entering.
• Never run dextrose or parenteral nutrition through the pressure line.
• The catheter is replaced only for a clinical reason, not on a schedule. Transducers are replaced every 96 hours, with their tubing and flush; the line comes out as soon as it's no longer needed.
• In intensive care, central lines can measure central venous pressure, and a catheter in the lung artery shows how well the heart is pumping.